title: Is there a role for surgery for patients with a complete clinical response after chemoradiation for esophageal cancer? An intention-to-treat case-control study.
abstract: OBJECTIVE
  To compare the outcomes of a strategy of surveillance versus surgical resection in patients with esophageal cancer (EC) experiencing complete clinical response (cCR) after chemoradiation (CRT).
  
  
  BACKGROUND
  In EC, it remains unclear whether a strategy of surveillance or esophagectomy is appropriate after cCR to CRT.
  
  
  METHODS
  From 1995 to 2009, 222 operable patients had a cCR based on the results of a computed tomographic scan, endoscopy with biopsies and, when performed, a positron emission tomographic scan. Through an intention-to-treat case-control study, 59 patients treated with CRT and surveillance (group Surv) were matched 1:2 with 118 patients treated by CRT followed by surgery (group Surg), according to age, gender, tumor location and stage, histology, American Society of Anesthesiologists score, and nutritional status.
  
  
  RESULTS
  The 2 groups were comparable according to the matched variables (P > 0.276). In group Surg, the postoperative mortality rate was 4.2% with evidence of residual tumor in 34.6% of specimens. In group Surv, 2 salvage esophagectomies were performed. Despite the higher dose of radiotherapy received in group Surv (50 vs 45 Gys, P = 0.003), median survival was lower (31 vs 83 months, P = 0.001), with disease recurrence that was more frequent (50.8% vs 32.7%, P = 0.021), occurred earlier (7.8 vs 19.0 months, P = 0.002) and more often locoregional (46.7% vs 16.2%, P = 0.007) in nature. Surgical resection was independently associated with less recurrence [odds ratio = 0.4, 95% confidence interval (CI): 0.2-0.8, P = 0.006] and better survival (hazard ratio = 0.5, 95% CI: 0.3-0.8, P = 0.006).
  
  
  CONCLUSIONS
  Survival of EC patients with a cCR after CRT is better after surgery compared to simply surveillance. In patients of low operative risk and operable disease, surgery should be considered to improve control of locoregional disease and to overcome the inherent limitations of clinical response assessment.
authors.affiliation: *Department of Digestive and Oncological Surgery, University Hospital of Lille †University of Lille-Nord de France ‡Inserm, Jean-Pierre Aubert Research Center, Lille Cedex §Academic Radiotherapy Department ¶Gastrointestinal Oncology Department, CLCC Oscar Lambret Comprehensive Cancer Center, Lille cedex, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Piessen
authors.forename: Mathieu
authors.initials: M
authors.lastname: Messager
authors.forename: Xavier
authors.initials: X
authors.lastname: Mirabel
authors.forename: Nicolas
authors.initials: N
authors.lastname: Briez
authors.forename: William B
authors.initials: WB
authors.lastname: Robb
authors.forename: Antoine
authors.initials: A
authors.lastname: Adenis
authors.forename: Christophe
authors.initials: C
authors.lastname: Mariette
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy; D016022:Case-Control Studies; D059248:Chemoradiotherapy; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000601:surgery / Q000628:therapy*; D016629:Esophagectomy; D004945:Esophagoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome